Diffusion tensor imaging parameters in mild traumatic brain injury and its correlation with early neuropsychological impairment: a longitudinal study

We explored the prognostic value of diffusion tensor imaging (DTI) parameters of selected white matter (WM) tracts in predicting neuropsychological outcome, both at baseline and 6 months later, among well-characterized patients diagnosed with mild traumatic brain injury (mTBI). Sixty-one patients with mTBI (mean age=27.08; standard deviation [SD], 8.55) underwent scanning at an average of 10 h (SD, 4.26) post-trauma along with assessment of their neuropsychological performance at an average of 4.35 h (SD, 7.08) upon full Glasgow Coma Scale recovery. Results were then compared to 19 healthy control participants (mean age=29.05; SD, 5.84), both in the acute stage and 6 months post-trauma. DTI and neuropsychological measures between acute and chronic phases were compared, and significant differences emerged. Specifically, chronic-phase fractional anisotropy and radial diffusivity values showed significant group differences in the corona radiata, anterior limb of internal capsule, cingulum, superior longitudinal fasciculus, optic radiation, and genu of corpus callosum. Findings also demonstrated associations between DTI indices and neuropsychological outcome across two time points. Our results provide new evidence for the use of DTI as an imaging biomarker and indicator of WM damage occurring in the context of mTBI, and they underscore the dynamic nature of brain injury and possible biological basis of chronic neurocognitive alterations

Missense mutation of Brain Derived Neurotrophic Factor (BDNF) alters neurocognitive performance in patients with mild traumatic brain injury: a longitudinal study

The predictability of neurocognitive outcomes in patients with traumatic brain injury is not straightforward. The extent and nature of recovery in patients with mild traumatic brain injury (mTBI) are usually heterogeneous and not substantially explained by the commonly known demographic and injury-related prognostic factors despite having sustained similar injuries or injury severity. Hence, this study evaluated the effects and association of the Brain Derived Neurotrophic Factor (BDNF) missense mutations in relation to neurocognitive performance among patients with mTBI. 48 patients with mTBI were prospectively recruited and MRI scans of the brain were performed within an average 10.1 (SD 4.2) hours post trauma with assessment of their neuropsychological performance post full Glasgow Coma Scale (GCS) recovery. Neurocognitive assessments were repeated again at 6 months follow-up. The paired t-test, Cohen’s d effect size and repeated measure ANOVA were performed to delineate statistically significant differences between the groups [wildtype G allele (Val homozygotes) vs. minor A allele (Met carriers)] and their neuropsychological performance across the time point (T1 = baseline/ admission vs. T2 = 6th month follow-up). Minor A allele carriers in this study generally performed more poorly on neuropsychological testing in comparison wildtype G allele group at both time points. Significant mean differences were observed among the wildtype group in the domains of memory (M = -11.44, SD = 10.0, p = .01, d = 1.22), executive function (M = -11.56, SD = 11.7, p = .02, d = 1.05) and overall performance (M = -6.89 SD = 5.3, p = .00, d = 1.39), while the minor A allele carriers showed significant mean differences in the domains of attention (M = -11.0, SD = 13.1, p = .00, d = .86) and overall cognitive performance (M = -5.25, SD = 8.1, p = .01, d = .66).The minor A allele carriers in comparison to the wildtype G allele group, showed considerably lower scores at admission and remained impaired in most domains across the timepoints, although delayed signs of recovery were noted to be significant in the domains attention and overall cognition. In conclusion, the current study has demonstrated the role of the BDNF rs6265 Val66Met polymorphism in influencing specific neurocognitive outcomes in patients with mTBI. Findings were more detrimentally profound among Met allele carriers

Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury

Abstract: Background: Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. Methods: The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. Results: The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. Conclusions: In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction

Outcome of 1939 traumatic brain injury patients from road traffic accidents: Findings from specialist medical reports in a low to middle income country (LMIC).

ObjectiveRoad traffic accident (RTA) is the major cause of traumatic brain injury (TBI) in developing countries and affects mostly young adult population. This research aimed to describe the factors predicting functional outcome after TBI caused by RTA in a Malaysian setting.MethodsThis was a retrospective cross-sectional study conducted on specialist medical reports written from 2009 to 2019, involving patients who survived after TBI from RTA. The functional outcome was assessed using the Glasgow Outcome Scale-Extended (GOSE). Factors associated with good outcome were analysed via logistic regression analysis. Multivariate logistic regression analysis was used to derive the best fitting Prediction Model and split-sample cross-validation was performed to develop a prediction model.ResultsA total of 1939 reports were evaluated. The mean age of the study participants was 32.4 ± 13.7 years. Most patients were male, less than 40, and with average post RTA of two years. Good outcome (GOSE score 7 & 8) was reported in 30.3% of the patients. Factors significantly affecting functional outcome include age, gender, ethnicity, marital status, education level, severity of brain injury, neurosurgical intervention, ICU admission, presence of inpatient complications, cognitive impairment, post-traumatic headache, post traumatic seizures, presence of significant behavioural issue; and residence post discharge (pConclusionGood functional outcome following TBI due to RTA in this study population is comparable to other low to middle income countries but lower than high income countries. Factors influencing outcome such as seizure, cognitive and behavioural issues, and independent living post injury should be addressed early to achieve favourable long-term outcomes

Equitable Access to State-of-the-Art Medical Technology-a Malaysian Mini-Public-Private Partnership Case Study.

BACKGROUND: The provision of equitable and affordable health care has become increasingly challenging as advanced technology is introduced, particularly in developing countries. We explored the hypothesis that focused, small-scale mini-public-private partnerships have a potential role in providing equitable and affordable access to advanced technology for the benefit of all patients in developing nations, particularly middle-income countries. METHODS: A clinician-led financial plan was developed at the University of Malaya to create the Centre for Image Guidance and Minimally Invasive Therapy (CIGMIT) to provide an integrated platform for high-end care for Malaysian patients of all ages, both public and private, requiring complex neurosurgical and spinal procedures and stereotactic and intensity-modulated radiotherapy. The challenges faced during development of the plan were documented together with an audit of patient throughput and analyses of financial risk and return. RESULTS: CIGMIT opened in 2015. Patient throughput, both public and private, progressively increased in all facilities. In 2015-2019, 37,724 patients used the Centre's facilities. CIGMIT has become progressively more profitable for the University of Malaya, the public and private hospitals, and the investor. CIGMIT has weathered the challenges posed by coronavirus disease 19. CONCLUSIONS: Focused, small-scale mini-public-private partnerships have a potential role in providing advanced technology for the benefit of patients in developing nations, particularly middle-income countries, subject to an approach that balances equity of access between public and private health care systems with fair reward

Frequency and Causes of Line of Sight Issues During Neurosurgical Procedures Using Optical Image-Guided Systems

Background: Navigation (image guidance) is an essential tool in modern neurosurgery, and most surgeons use an optical tracking system. Although the technology is accurate and reliable, one often is confronted by line of sight issues that interrupt the flow of an operation. There has been feedback on the matter, but the actual problem has not been accurately quantified, therefore making this the primary aim of this study. It is particularly important given that robotic technology is gradually making its way into neurosurgery and most of these devices depend on optical navigation when procedures are being conducted. Methods: In this study, the frequency and causes of line of sight issues is assessed using recordings of Navigation probe locations and its synchronised video recordings. Results: The mentioned experiment conducted for a series of 15 neurosurgical operations. This issue occured in all these surgeries except one. Maximum duration of issue presisting reached up to 56% of the navigation usage time. Conclusions: The arrangment of staff and equipment is a key factor in avoiding this issue. © 2018 Elsevier Inc

Cognitive impairments in mild traumatic brain injury and genetic polymorphism of apolipoprotein E: a preliminary study in a Level I trauma center

The complex pathophysiology of traumatic brain injury, its cascading effects and a varied outcome suggest that factors such as genetics may permeate and modulate the neurocognitive outcomes in patients with mild traumatic brain injury (mTBI). This study was conducted to determine the relationship between genetic polymorphism of apolipoprotein E, and neurocognitive and functional outcomes in mTBI. Twenty-one patients with mTBI were recruited prospectively. The severity of the injury was established with the Glasgow Coma Score (GCS). Other assessments included the CT Scan of the head on admission, Disability Rating Scale, Chessington Occupational Therapy Neurological Assessment (COTNAB) and Glasgow Outcome Scale (GOS). The Spearmen correlation analysis of ApoE allele status and the cognitive and functional assessments saw some association with the Sensory Motor Ability - Coordination (-0.526, p<0.05), Communication Ability (-0.651, p<0.05), and the Employability (Return to Work) at 1st month (0.455, p<0.05). Notably, the deficits of specific attributes of visuospatial and sensory motor function were seen with greater impairment consistently observed in patients with ApoE e4 allele. In conclusion, the preliminary findings support the possible relationship that exists between ApoE e4 and neurocognitive impairment in mTBI, despite good functional recovery in 6 months post injury